Comparative Effectiveness of Prasugrel versus Ticagrelor in Dialysis-Dependent end stage renal disease Patients Undergoing Percutaneous Coronary Intervention.

End-stage renal disease (ESRD) patients undergoing percutaneous coronary intervention (PCI) represent a high-risk, understudied population in whom optimal P2Y₁₂ inhibition remains undefined. Landmark trials demonstrated the superiority of prasugrel and ticagrelor over clopidogrel; however, ESRD patients were largely excluded. We aimed to compare the effectiveness and safety of prasugrel versus ticagrelor in a real-world cohort of dialysis-dependent ESRD patients undergoing PCI. Using a large US-based electronic health record network, we identified 920 propensity-score matched pairs of ESRD patients on dialysis who received either prasugrel or ticagrelor following PCI between 2011 and 2024. The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), or stroke, defined as Major Adverse Cardiovascular Events (MACE). Over a median follow-up duration of 11.2 months, prasugrel was associated with a significantly lower risk of all-cause mortality (Hazard Ratio [HR] 0.72, 95% Confidence Interval [CI] 0.56-0.92, p=0.025) compared to ticagrelor. There were no significant differences in the rates of MI, stroke, or major bleeding between the two groups, although there was a trend toward lower major bleeding with prasugrel (p=0.06). In conclusion, in this large, real-world study of ESRD patients on dialysis undergoing PCI, prasugrel was associated with a lower risk of all-cause mortality compared to ticagrelor, without an increased risk of major bleeding.